31: Pediatric Emergencies

6-1.1 Identify the developmental considerations for the following pediatric age groups: infants, toddlers, preschool, school age, adolescent Describe the differences in anatomy and physiology between the infant, the child, and the adult patient Differentiate the response of the ill or injured infant or child (age specific) from that of an adult. Cognitive Objectives (1 of 3)

6-1.8 Identify the signs and symptoms of shock (hypoperfusion) in an infant and child patient List common causes of seizures in the infant and child patient Differentiate between the injury patterns in adults, infants, and children. Cognitive Objectives (2 of 3)

Cognitive Objectives (3 of 3) Summarize the indicators of possible child abuse and neglect Describe the medical/legal responsibilities in suspected child abuse Recognize the need for EMT-B debriefing following a difficult infant or child transport.

Affective Objectives Explain the rationale for having knowledge and skills appropriate for dealing with the infant and child patient Attend to the feelings of the family when dealing with an ill or injured infant or child Understand the provider’s own response (emotional) to caring for infants or children. There are no psychomotor objectives for this chapter.

Airway Differences Larger tongue relative to the mouth Larger epiglottis Less well-developed rings of cartilage in the trachea Narrower, lower airway

Breathing Differences Infants breathe faster than children or adults. Infants use the diaphragm when they breathe. Sustained, labored breathing may lead to respiratory failure.

Circulation Differences The heart rate increases for illness and injury. Vasoconstriction keeps vital organs nourished. Constriction of the blood vessels can affect blood flow to the extremities.

Skeletal Differences Bones are weaker and more flexible. –They are prone to fracture with stress. Infants have two small openings in the skull called fontanels. –Fontanels close by 18 months.

Growth and Development Thoughts and behaviors of children usually grouped into stages –Infancy –Toddler years –Preschool age –School age –Adolescence

Infant First year of life They respond mainly to physical stimuli. Crying is a way of expression. They may prefer to be with caregiver. If possible, have caregiver hold the infant as you start your examination.

Toddler 1 to 3 years of age They begin to walk and explore the environment. They may resist separation from caregivers. Make any observations you can before touching a toddler. They are curious and adventuresome.

Preschool 3 to 6 years of age They can use simple language effectively. They can understand directions. They can identify painful areas when questioned. They can understand when you explain what you are going to do using simple descriptions. They can be distracted by using toys.

School Age 6 to 12 years of age They begin to think like adults. They can be included with the parent when taking medical history. They may be familiar with physical exam. They may be able to make choices.

Adolescent 12 to 18 years of age They are very concerned about body image. They may have strong feelings about being observed. Respect an adolescent’s privacy. They understand pain. Explain any procedure that you are doing.

Family Matters When a child is ill or injured, you have several patients, not just one. Caregivers often need support when medical emergencies develop. Children often mimic the behavior of their caregivers. Be calm, professional, and sensitive.

Pediatric Emergencies (1 of 3) Dehydration –Vomiting and diarrhea –Greater risk than adults Fever –Rarely life threatening –Caution if occurring with rash

Pediatric Emergencies (2 of 3) Meningitis is an inflammation of the tissue that covers the spinal cord and brain. Caused by an infection If left untreated can lead to brain damage or death.

Pediatric Emergencies (3 of 3) Febrile seizures –Common between 6 months and 6 years –Last less than 15 minutes Poisoning –Signs and symptoms vary widely. –Determine what substances were involved.

Physical Differences Children and adults suffer different injuries from the same type of incident. Children’s bones are less developed than an adult’s. A child’s head is larger than an adult’s, which greatly stresses the neck in deceleration injuries.

Psychological Differences Children are not as psychologically mature. They are often injured due to their undeveloped judgment and lack of experience.

Injury Patterns: Automobile Collisions The exact area of impact will depend on the child’s height. A car bumper dips down when stopping suddenly, causing a lower point of impact. Children often sustain high-energy injuries.

Injury Patterns: Sports Activities Head and neck injuries can occur from high- speed collisions during contact sports. Immobilize the cervical spine. Follow local protocols for helmet removal.

Head Injuries Common injury among children The head is larger in proportion to an adult. Nausea and vomiting are signs of pediatric head injury.

Chest Injuries Most chest injuries in children result from blunt trauma. Children have soft, flexible ribs. The absence of obvious external trauma does not exclude the likelihood of serious internal injuries.

Abdominal Injuries Abdominal injuries are very common in children. Children compensate for blood loss better than adults but go into shock more quickly. Watch for: –Weak, rapid pulse –Cold, clammy skin –Poor capillary refill

Injuries to the Extremities Children’s bones bend more easily than adults’ bones. Incomplete fractures can occur. Do not use adult immobilization devices on children unless the child is large enough.

Pneumatic Antishock Garments (PASG) Rarely used for treating children When to use a PASG: –Obvious lower extremity trauma –Pelvic instability –Clear signs and symptoms of decompensated shock Should only be used if it fits properly Should never inflate the abdominal compartment

Burns Most common burns involve exposure to hot substances. Suspect internal injuries from chemical ingestion when burns are present around lips and mouth. Infection is a common problem with burns. Consider the possibility of child abuse.

Submersion Injury Drowning or near drowning Second most common cause of unintentional death of children in the United States Assessment and reassessment of ABCs are critical. Consider the need for C-spine protection.

Child Abuse Child abuse refers to any improper or excessive action that injures or harms a child or infant. This includes physical abuse, sexual abuse, neglect, and emotional abuse. More than 2 million cases are reported annually. Be aware of signs of child abuse and report suspicions to authorities.

Signs of Child Abuse

Questions Regarding Signs of Abuse (1 of 4) Is the injury typical for the child’s developmental stage? Is reported method of injury consistent with injuries? Is the caregiver behaving appropriately? Is there evidence of drinking or drug abuse?

Questions Regarding Signs of Abuse (2 of 4) Was there a delay in seeking care for the child? Is there a good relationship between child and caregiver? Does the child have multiple injuries at various stages of healing? Does the child have any unusual marks or bruises?

Questions Regarding Signs of Abuse (3 of 4) Does the child have several types of injuries? Does the child have burns on the hands or feet involving a glove distribution? Is there an unexplained decreased level of consciousness?

Questions Regarding Signs of Abuse (4 of 4) Is the child clean and an appropriate weight? Is there any rectal or vaginal bleeding? What does the home look like? Clean or dirty? Warm or cold? Is there food?

Emergency Medical Care EMT-Bs must report all suspected cases of child abuse. Most states have special forms for reporting. You do not have to prove that abuse occurred.

Sexual Abuse Children of any age or either sex can be victims. Limit examination. Do not allow child to wash, urinate, or defecate. Maintain professional composure. Transport.

Sudden Infant Death Syndrome (SIDS) Several known risk factors: –Mother younger than 20 years old –Mother smoked during pregnancy –Low birth weight

Tasks at Scene Assess and manage the patient. Communicate with and support the family. Assess the scene.

Assessment and Management Assess ABCs and provide interventions as necessary. If child shows signs of postmortem changes, call medical control. If there is no evidence of postmortem changes, begin CPR immediately.

Communication and Support The death of a child is very stressful for the family. Provide support in whatever ways you can. Use the infant’s name. If possible, allow the family time with the infant.

Scene Assessment Carefully inspect the environment, following local protocols. Concentrate on: –Signs of illness –General condition of the house –Family interaction –Site where infant was discovered

Apparent Life-Threatening Event Infant found not breathing, cyanotic, and unresponsive but resumes breathing with stimulation Complete careful assessment. Transport immediately. Pay strict attention to airway management.

Death of a Child (1 of 2) Be prepared to support the family. Family may insist on resuscitation efforts. Introduce yourself to the child’s caregivers. Do not speculate on the cause of death.

Death of a Child (2 of 2) Allow the family to see the child and say good-bye. Be prepared to answer questions posed by caregivers. Seek professional help for yourself if you notice signs of posttraumatic stress.

Children With Special Needs Children born prematurely who have associated lung problems Small children or infants with congenital heart disease Children with neurologic diseases Children with chronic diseases or with functions that have been altered since birth

Tracheostomy Tube

Artificial Ventilators Provide respirations for children unable to breathe on their own. If ventilator malfunctions, remove child from the ventilator and begin ventilations with a BVM device. Ventilate during transport.

Central IV Lines

Gastrostomy Tubes Food can back up the esophagus into the lungs. Have suction readily available. Give supplemental oxygen if the patient has difficulty breathing.

Shunts Tubes that drain excess fluid from around brain If shunt becomes clogged, changes in mental status may occur. If a shunt malfunctions, the patient may go into respiratory arrest.